General Practitioners’ and patients’ perceptions towards stratified care: a theory informed investigation

Abstract

BackgroundStratified primary care involves changing General Practitioners’ (GPs) clinical behaviour in treating patients, away from the current stepped care approach to instead identifying early treatment options that are matched to patients’ risk of persistent disabling pain. This article explores the perspectives of UK-based GPs and patients about a prognostic stratified care model being developed for patients with the five most common primary care musculoskeletal pain presentations. The focus was on views about acceptability, and anticipated barriers and facilitators to the use of stratified care in routine practice.MethodsFour focus groups and six semi-structured telephone interviews were conducted with GPs (n = 23), and three focus groups with patients (n = 20). Data were analysed thematically; and identified themes examined in relation to the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. A critical approach was taken in using the TDF, examining the nuanced interrelationships between theoretical domains.ResultsFour key themes were identified: Acceptability of clinical decision-making guided by stratified care; impact on the therapeutic relationship; embedding a prognostic approach within a biomedical model; and practical issues in using stratified care. Whilst within each theme specific findings are reported, common across themes was the identified relationships between the theoretical domains of knowledge, skills, professional role and identity, environmental context and resources, and goals. Through analysis of these identified relationships it was found that, for GPs and patients to perceive stratified care as being acceptable, it must be seen to enhance GPs’ knowledge and skills, not undermine GPs’ and patients’ respective identities and be integrated within the environmental context of the consultation with minimal disruption.ConclusionsFindings highlight the importance of taking into account the context of general practice when intervening to support GPs to make changes to their clinical behaviour. Findings will inform further stages of the research programme; specifically, the intervention format and content of support packages for GPs participating in a future randomised controlled trial (RCT). This study also contributes to the theoretical debate on how best to encourage clinical behaviour change in general practice, and the possible role of the TDF in that process.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0511-2) contains supplementary material, which is available to authorized users.

Stratified primary care versus non-stratified care for musculoskeletal pain: qualitative findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

“…Findings reported here show both similarities and differences with other qualitative studies into stratified care for MSK pain [32][33][34], including our own earlier paper [19]. In our 2016 paper, some similar barriers were anticipated to those found here, such as difficulty integrating the tool within the consultation time-frame; disruption to the flow of the consultation; and the lack of availability of some matched treatment options.…”

“…Delivering prognostic stratified care in MSK consultations clearly requires a change in GP and patient behaviour; not only in integrating the new tool and matched treatments as part of the IT template within consultations, but also moving away from the stepped care model often involving a predominantly biomedical approach centring on diagnosis [18], to integrating information about prognostic factors that include psychosocial obstacles to recovery. The challenges in changing consultation behaviour were highlighted in an earlier, preparatory study published in this journal, which explored patients' and GPs' views on the acceptability and anticipated barriers and facilitators to using stratified care [19]. Whilst this earlier work found stratified care was broadly acceptable to patients and GPs, potential barriers to its use were reported; including anticipated difficulties in integrating it within the consultation time-frame, and concerns that it may disrupt the flow of the consultation and undermine clinical autonomy.…”

Physiotherapists’ views of implementing a stratified treatment approach for patients with low back pain in Germany: a qualitative study

“…Others argued that a differentiation in treatment approach for patients with a shorter or longer history of complaints might be necessary. Like the discussions with physicians [ 35 , 48 ], controversial aspects included the time required for SBT administration and its potential influence on professional-patient communication. Some recommended that patients be stratified before the consultation, while others indicated their preference for using it as part of their clinical assessment.…”

Matching treatment options for risk sub-groups in musculoskeletal pain: a consensus groups study

“…Whilst we recognise that expert patients would have valuable input for decisions about treatment options, it was felt that this study was specifically about clinical expertise and therefore was limited to clinician input. Extensive patient representation has been included in the broader research programme [6], and the development and testing of the stratified primary care intervention.…”

“…Musculoskeletal (MSK) pain represents a considerable worldwide healthcare burden [1] and, in the UK, accounts for 14% of all general practice (GP) consultations [2]. Individual GP treatment is highly variable [3], which may be in part due to a lack of confidence in managing these problems [4], as well as MSK pain being given lower priority when compared with other acute illnesses with more medically critical symptoms [5, 6]. A key result of this variability in management is that some patients may, at least initially, receive suboptimal care including inappropriate treatment referrals, whilst others fail to receive appropriate early referral [7, 8].…”